A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)
Evaluate neurologic status every 8 hr.
Provide a dark, quiet environment.
Administer magnesium sulfate IV.
Ensure that calcium gluconate is readily available.
Assess respiratory status every 4 hr.
Correct Answer : B,C,D
Explanation:
A. Evaluate neurologic status every 8 hr.
While monitoring neurologic status is important in clients with severe gestational hypertension to assess for signs of impending eclampsia (seizures), more frequent monitoring is typically required, such as every 4 hours or even more frequently depending on the severity of the condition. Therefore, evaluating neurologic status every 8 hours is not sufficient for this client.
B. Provide a dark, quiet environment.
Creating a calm and low-stimulation environment helps to reduce the risk of seizures, which can be triggered by bright lights and loud noises in clients with severe gestational hypertension.
C. Administer magnesium sulfate IV.
Magnesium sulfate is commonly used to prevent seizures in clients with severe gestational hypertension (preeclampsia). It is a standard treatment to prevent eclampsia, a serious complication of preeclampsia characterized by seizures. Therefore, the nurse should expect to administer magnesium sulfate IV as part of the management plan for severe gestational hypertension.
D. Ensure that calcium gluconate is readily available.
Magnesium sulfate, while effective in preventing seizures, can lead to magnesium toxicity if levels become too high. Calcium gluconate is the antidote for magnesium sulfate toxicity. Therefore, the nurse should ensure that calcium gluconate is readily available to counteract any potential magnesium toxicity that may occur during magnesium sulfate administration.
E. Assess respiratory status every 4 hr.
Monitor and record vital signs (blood pressure, pulse, respirations, O2 saturation) every 1 hour x’s 8 hours after maintenance infusion is started and vital signs for bolus infusion are complete. If respiratory rate < 12 breaths/min, draw magnesium level, notify HCP, and observe closely.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Explanation:
A. Preeclampsia: Preeclampsia is a condition characterized by high blood pressure and signs of damage to other organs, typically occurring after 20 weeks of pregnancy. While preeclampsia is a concern during pregnancy, it is not directly related to abruptio placentae or the development of DIC.
B. Puerperal infection: Puerperal infection refers to an infection that occurs after childbirth. Although infections are a concern in the postpartum period, they are not specifically associated with abruptio placentae or the development of DIC unless there are additional risk factors or complications.
C. Anaphylactoid syndrome of pregnancy: Anaphylactoid syndrome of pregnancy (also known as amniotic fluid embolism) is a rare but serious condition where amniotic fluid enters the maternal circulation, potentially causing a severe allergic-like reaction. This condition is not directly related to abruptio placentae or the development of DIC.
D. Disseminated intravascular coagulation (DIC): This is the correct answer. DIC is a serious condition where the body's clotting mechanisms are abnormally activated, leading to widespread clot formation in small blood vessels. It can result from various conditions, including abruptio placentae, especially when there is evidence of bleeding such as petechiae and bleeding around the IV access site. DIC can lead to both bleeding tendencies and clot formation, affecting multiple organs and potentially causing severe complications.
Correct Answer is C
Explanation
Explanation:
A. Pattern of contractions: While the pattern of contractions is important in assessing labor progress, it alone may not differentiate between true labor and false labor (also known as Braxton Hicks contractions). True labor contractions typically become longer, stronger, and more frequent over time, but other factors must also be considered to confirm true labor.
B. Rupture of the membranes: Rupture of the membranes (water breaking) can occur during both true labor and false labor. However, it is not a definitive sign of true labor on its own, as it can also happen spontaneously or due to other reasons.
C. Changes in the cervix: This is the correct answer. True labor is characterized by progressive changes in the cervix, including effacement (thinning) and dilation (opening). These changes can be confirmed through a cervical examination performed by a healthcare provider.
D. Station of the presenting part: The station of the presenting part refers to the position of the baby's head in relation to the mother's pelvis. While the station can provide information about the progress of labor, it is not a specific sign of true labor by itself.
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